Provider Demographics
NPI:1073614566
Name:HERBST, MICHELLE (MPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HERBST
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 NW 86TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-2284
Mailing Address - Country:US
Mailing Address - Phone:515-278-8151
Mailing Address - Fax:515-278-8155
Practice Address - Street 1:1555 SE DELAWARE AVE
Practice Address - Street 2:SUITE M
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-4011
Practice Address - Country:US
Practice Address - Phone:515-963-8723
Practice Address - Fax:515-963-8755
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665430Medicaid
IAI19172Medicare PIN
IA166583Medicare ID - Type Unspecified
IA0665430Medicaid